Overview
The below information is in regards to the base rate codes programs should use when billing Medicaid as well as the rates paid out based on those codes for providing any services covered under New York State Regulation Part 822. General Service Standards for Substance Use Disorder Outpatient Programs.
The downstate peer group includes New York County, Kings County, Queens County, Richmond County, Bronx County, Nassau, Suffolk, Westchester, Rockland, Putnam, Dutchess and Orange counties. The upstate peer group refers to the rest of New York State (ROS).
-
Ambulatory Patient Group Manual
Rate codes, procedure codes and service description codes for both fee for service and managed care billing in Outpatient SUD, Opioid Treatment Programs and Integrated Services settings.
Download
-
APG Procedure Codes
Ambulatory Patient Group procedure codes and limitations for billing Medicaid fee-for-service.
Download
-
Coding Taxonomy
Coding Crosswalk including Rate Code, Procedure Code and Modifiers for Health and Recovery Plans (HARP) and Mainstream Behavioral Health Carve in Services
Download
Revenue Calculators
OASAS developed the APG Medicaid Revenue Calculator to simulate Medicaid revenue projections associated with APG pricing.
Certified outpatient programs may use the tool to continuously monitor and update their projected APG Medicaid revenues. Calculator have the base rates for the respective programs/peer groups; and, the application of the phased payments.
Outpatient Services
Ambulatory Patient Group (APG) and Federally Qualified Health Center (FQHC) base rates and reimbursement codes for certified outpatient clinics or outpatient rehabilitation programs.
Learn more and find guidance pertaining to outpatient Part 822 services, here.
-
Article 32 Freestanding Outpatient APG Rates
Ambulatory Patient Group Rates for all Freestanding Outpatient levels of care.
Download
-
Article 32 Hospital Outpatient APG Rates
Ambulatory Patient Group Rates for all Hospital Based Outpatient levels of care.
Download
-
Peer Service Reimbursement Code Change
Letter to outpatient treatment providers outlining the transition for peer services from the Enhanced Rate Code to the Standard Rate Code
Download
-
Peer Service Reimbursement Code Change
Letter to Medicaid Managed Care plans regarding the transition of peer services from the Enhanced Rate Code to the Standard Rate Code.
Download
Opioid Treatment Programs
-
APG Base Rates for Opioid Treatment Programs (OTPs)
Ambulatory Patient Group base rates for freestanding OASAS OTPs, hospital-based OTPs, and Article 28 providers.
Download
-
Dual Billing Guidance for Opioid Treatment Programs
Effective January 1, 2021, OTP providers billing services for individuals eligible for both Medicare and Medicaid should not bill Medicaid until a claim has been processed by Medicare.
Download
-
Guidance on OTP Bundled Codes & Fees
Bundled OTP rates have been calculated consistent with the Medicare bundles and are adjusted for regional factors. Effective August 1, 2021, OTPs may elect to bill either bundled rates or APGs so long as they only bill one methodology for a patient in a given week.
Download
-
Hepatitis C Treatment Billing & Reimbursement
New York State guidance on reimbursement for HCV-related counseling, testing, and treatment services in OTPs and other programs with appropriate medical staffing.
Download
Medication Billing
Guidance on billing Sublocade intramuscular injection and oral buprenorphine in ambulatory settings), as well as billing for Vivitrol for outpatient programs.
Please note that changes to Chapters 69 and 71 of the Insurance Laws of 2016 prohibit prior Insurance authorization for medications for treatment of substance use disorder.
-
Buprenorphine Billing
Information on billing for buprenorphine in outpatient clinic or rehabilitation settings and in opioid treatment programs (OTPs).
Download
-
Billing for Medication Management
An OASAS and Office of Mental Health memo on billing medication management for co-occurring disorders.
Download
Contact Practice Innovation & Care Management Unit
If you have any questions, contact the Division of Practice Innovation and Care Management (PICM).